Fish allergy in atopic children

The prevalence of fish allergy among 11 atopic children with elevated levels of specific immunoglobulin (Ig) E for cod was determined. None of the children had a history of fish allergy. All of the children had asthma and allergic rhinitis and 5 of them had also atopic dermatitis. The children underwent allergy skin tests (codfish, tuna, catfish, salmon, flounder, and bass), specific IgE tests (salmon, trout, tuna, eel, and mackerel), and food challenge tests. Skin tests in cod-specific IgE-positive children were positive for codfish in 4 children, tuna in 2, catfish in 2, salmon in 6, flounder in one, and bass in 2. Three children had elevated specific IgE for salmon, 5 for trout, 8 for tuna, 4 for eel, and 4 for mackerel. Oral fish challenge with 10 g of fish did not result in positive reaction in any of the children. In conclusion, a positive food challenge test provided the only definitive confirmation of fish allergy, whereas positive allergy skin tests or positive specific IgE tests were less reliable. Skin tests and in vitro specific IgE assays were not correlated with clinical symptoms of fish allergy, and the results of these 2 tests did not correlate with each other in this study.

Reactive oxygen species activity, mucosal lipoperoxidation and glutathione in Helicobacter pylori-infected gastric mucosa

BACKGROUND AND AIM

Helicobacter pylori is considered as the major pathogen in Helicobacter pylori-associated gastroduodenal disease, but the mechanism of its action has not been fully explained. This study was performed to assess the reactive oxygen species activity and the damage in Helicobacter pylori-infected gastric mucosa.

METHODS

Gastric biopsy specimens were obtained from 308 patients undergoing endoscopy. Gastric mucosal damage was assessed by using luminol enhanced chemiluminescence, thiobarbituric acid-reactive substance, and mucosal glutathione.

RESULTS

The chemiluminescence and thiobarbituric acid-reactive substance-equivalent levels in the mucosa of patients with Helicobacter pylori-positive gastric mucosa (43.8 +/- 134.9 c.p.m./microg tissue, 157.0 +/- 96.2 nmol/g tissue, respectively) were significantly higher than in those with Helicobacter pylori-negative mucosa (6.8 +/- 20.3 c.p.m./microg tissue, 110.0 +/- 51.6 nmol/g tissue, respectively; P=0.000, P=0.016, respectively). The glutathione levels in the mucosa of patients with Helicobacter pylori-positive gastric mucosa (159.3 +/- 76.6 nmol/microg tissue) were significantly lower than in those with Helicobacter pylori-negative gastric mucosa (212.3 +/- 134.3 nmol/microg tissue; P=0.008). After the data were divided according to the presence of Helicobacter pylori, there were no significant differences in chemiluminescence, thiobarbituric acid-reactive substance, and glutathione among the different macroscopic findings within Helicobacter pylori-positive and -negative gastric mucosa.

CONCLUSIONS

Helicobacter pylori infection plays a pathological role in many gastrointestinal diseases through excessive mucosal-reactive oxygen species production, pronounced membrane damage, and the depletion of gastric anti-oxidants.

Survival after early surgical revascularization in patients with both acute myocardial infarction and cardiogenic shock

BACKGROUND AND PURPOSE

Previous studies have reported encouraging results with percutaneous transluminal coronary angioplasty (PTCA) in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock. However, PTCA is often unsuccessful and the mortality rate is more than 80%. The success rate of early surgical revascularization in patients with cardiogenic shock and failed PTCA is not clear. This study assessed the effect of early surgical revascularization on survival chances in patients with cardiogenic shock and failed PTCA.

PATIENTS AND METHODS

Nineteen patients referred to our hospital by cardiologists due to cardiogenic shock and failed PTCA were included in this study. During the period from February 1995 through August 1997, seven patients were treated using mechanical circulatory support with extracorporeal membrane oxygenation (ECMO) and no surgical revascularization, and from August 1997 through June 1999, 12 patients underwent emergency surgical revascularization. The patient characteristics and in-hospital mortality were compared between groups.

RESULTS

Ten patients were treated after acute infarction and nine were treated after cardiac intervention. No significant differences were found between the two groups in age, sex, hypertension, diabetes, smoking, and previous infarction. The in-hospital mortality rates were 100% in patients receiving mechanical circulatory support with ECMO and 25% in patients who underwent emergency surgical revascularization (p = 0.003). In the emergency revascularization group, four of 12 patients had surgical revascularization more than 18 hours after AMI and the in-hospital mortality rate was 25%.

CONCLUSION

Surgical revascularization improved survival in patients with cardiogenic shock and failed PTCA.

The dilemma of "to-be or not-to-be": needs and expectations of the Taiwanese cadaveric organ donor families during the pre-donation transition

There has been little study of the Chinese cadaveric donor family's decisions to donate organs within the Chinese cultural framework. A convenience sample of 25 cadaveric donor family members (12 men, 13 women) who gave their consent to donation at National Taiwan University Hospital agreed to participate in this study and completed in-depth interviews. Data were analyzed by a three-steps within-method qualitative triangulation method. The factors influencing the donor family's decisions to donate organs, the needs of donor families, and their expectations of health care providers during the pre-donation transition--the critical period of time between signing a donation and consent to organ harvesting--were examined. The background context and a conceptual framework were further developed to discuss and depict this phenomenon. This project aims to broaden the horizon on organ donation and contribute to the understanding of some of the psychodynamic issues in the Chinese family in Taiwan.

Lamivudine treatment for hepatitis B reactivation in HBsAg carriers after organ transplantation: a 4-year experience

BACKGROUND

Reactivation of hepatitis B after organ transplantation in hepatitis B surface antigen (HBsAg) carriers may be fatal. In this study, we reported our experience of lamivudine treatment in HBsAg carriers who had post-transplant reactivation of hepatitis B.

METHODS

The patients were 15 men and one woman. Nine received kidney transplants, six received heart transplants, and one received a lung transplant. They developed a reactivation of hepatitis B 1-101 months (median, 14 months) after transplantation. They received lamivudine 100 mg daily on a compassionate-use basis, and had regular follow ups. The median pretreatment total serum bilirubin level was 3.0 mg/dL, and the alanine aminotransferase level was 357 U/L. Four of the 16 patients were positive for HBeAg. The serum hepatitis B virus (HBV) DNA levels were > 3000 pg/mL in 13 (81%) patients. Three were coinfected with hepatitis C virus.

RESULTS

The overall survival rate was 75%. All four fatal cases had a pretreatment total serum bilirubin level of > or = 3 mg/dL. Serum HBV-DNA soon became undetectable in 12 survivors. Of the 12 survivors, after a median treatment period of 101 weeks, a lamivudine-resistant strain with variation in the YMDD motif of the HBV polymerase gene developed in three (25%). None had significant adverse reactions to lamivudine treatment.

CONCLUSIONS

These results indicated that lamivudine is effective in the treatment of post-transplant hepatitis B reactivation, including patients with dual chronic hepatitis B and C. Early recognition of HBV reactivation and prompt lamivudine treatment are important to prevent mortality.

Hepatitis B virus infection in heart transplant recipients in a hepatitis B endemic area

BACKGROUND

Hepatitis B virus (HBV) infection is hyperendemic in Taiwan. It is almost impossible for us to reject organ donors or recipients with positive serum hepatitis B surface antigen (HBsAg). We report our experience with HBV infection in heart transplant recipients with particular attention to outcome of recipients who were HBsAg+ or who had received donor hearts from HBsAg+ donors.

METHODS

We performed a retrospective review of medical records.

RESULTS

In the study, we included 101 heart recipients with post-transplant survival of more than 6 months. According to pre-transplant HBV serology markers, we divided patients into 4 groups. Group 1 (n = 8) had been HBsAg+ at the time of heart transplantation. Of these, 6 patients had HBV reactivation in the post-transplant follow-up and needed lamivudine treatment. Complete response was achieved in all 6 patients; however, HBV recurrence occurred in 1 patient after 8 months of lamivudine treatment. The recurrence remained under partial control. Group 2 (n = 16) was HBV naïve at the time of heart transplantation. Of these, 2 received HBsAg+ donor hearts under perioperative hepatitis B immunoglobulin prophylaxis. HBV infection was successfully prevented in 1 patient, but the other contracted HBV hepatitis, which was successfully treated with lamivudine. In Group 2, 10 patients received donor hearts from anti-HBs+ donors, and none contracted HBV hepatitis after transplantation. Group 3 (n = 55) had protective anti-HBs antibody at the time of heart transplantation either from previous HBV vaccination (n = 10) or from natural HGB infection (n = 45). HBsAg+ donor hearts were transplanted into 2 patients with anti-HBs from previous HBV vaccination, and into 8 patients with anti-HBs form natural HBV infection. However, none of these 10 patients who received HBsAg+ donor hearts had HBV hepatitis after transplantation. Group 4 (n = 22) was HBs-, anti-HBs-, and anti-HBc+ at the time of heart transplantation. Of these, 7 patients received HBsAg+ donor hearts. Six patients experienced no HBV hepatitis after heart transplantation, and serum HBV DNA by polymerase chain reaction (PCR) at the time of heart transplantation was negative in all 6 patients. One patient had HBV hepatitis after transplantation, and serum HBV DNA by PCR at the time of heart transplantation also was positive.

CONCLUSION

HBV reactivation after the heart transplantation was common but usually well controlled with lamivudine treatment. Therefore, HBV carrier status should not contraindicate heart transplantation. HBsAg+ donor hearts were safely transplanted into anti-HBs+ recipients; therefore, HBsAg+ itself was not a contraindication to heart donation. Patients with HBsAg-, anti-HBs-, anti-HBc+, and negative HBV DNA in the serum by PCR could be protected from HBV infection from HBsAg+ donor hearts. However, patients with HBsAg-, anti-HBs-, anti-HBc+, and positive HBV DNA in the serum by PCR should be recognized as HBV carriers and closely followed for potential HBV flare-up after heart transplantation.

Mechanical bridge with extracorporeal membrane oxygenation and ventricular assist device to heart transplantation

The aim of this study was to evaluate the effect of double bridges with extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs) in clinical heart transplantation. Between May 1994 and October 2000, 134 patients underwent heart transplantation at the National Taiwan University Hospital. Ten patients received ECMO or VAD support as bridges to transplantation. The ages ranged from 3 to 63 years. The indications included cardiac arrest under cardiopulmonary resuscitation in 2 and profound cardiogenic shock refractory to conventional therapy in 8 patients. Usually ECMO was first set up as rescue therapy. If ECMO could not be weaned off after short-term (usually 1 week) support, suitable VADs (HeartMate or Thoratec VAD) were implanted for medium-term or long-term support. Five patients received ECMO support as emergency rescue for 2 to 9 days, and then moved to Thoratec VAD for 8, 49, and 55 days, respectively, or centrifugal VAD for 31 days, or HeartMate VAD for 224 days. They all survived. The survival rate of double bridges with ECMO and VAD was 100%. In postcardiotomy cardiogenic shock, circulatory collapse from acute myocardial infarction or myocarditis, ECMO is the device of choice for short-term support. If heart transplantation is indicated, VADs should replace ECMO for their superiority as a bridge to heart transplantation. Our preliminary data of double bridges with ECMO and VAD revealed good results and were reliable and effective bridges to transplantation.

Conversion of extracorporeal membrane oxygenation to non-pulsatile left ventricular assist device. Is it out-of-date for non-pulsatile LVAD?

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) provides an immediate support for acute deterioration of hemodynamic and pulmonary status, but what is the best decision for these critical patients? Biventricular assist device (BVAD) or left ventricular assist device (LVAD)? We proposed a protocol of step-by-step conversion from ECMO to LVAD after assurance of the reversibility of right ventricle and pulmonary function.

METHODS

After femoral venoarterial ECMO was inserted for the critical patients, the left atrial drainage was added to the ECMO firstly and the femoral arterial inflow was shifted to the ascending aorta for preventing possible peripheral vascular complications. Temporary clamp of right heart drainage was tried to test right heart function 24 to 48 hours later. The sweep gas flow of oxygenator could be reduced gradually to test the pulmonary function. Therefore, the right heart drain and the oxygenator could be withdrawn to become a non-pulsatile LVAD or shift to pneumatic LVAD directly. There were four clinical experiences with successful conversion without temporary right ventricular assist device.

RESULTS

All of them were able to convert their ECMO to LVAD smoothly in 8.0+/-2.5 days. Three of them were shifted to non-pulsatile LVAD, and one was converted to HeartMate. All but one could be weaned from the ventilator. No BVAD was needed in these patients. Due to the shortage of donor hearts, only one had the chance to undergo heart transplantation.

CONCLUSIONS

The protocol did provide a good guideline for decision-making for those under ECMO support necessitating bridge to transplantation.

Development of a totally implantable pulsatile centrifugal pump as a ventricular assist device

The Taita No. 1 ventricular assist device (T-VAD) is a totally implantable pulsatile impeller centrifugal pump driven by a magnetically suspended motor. The flow can achieve 2.01 +/- 0.17 L/min against a pressure of 100 mm Hg under 0.266 +/- 0.017 amp and 13.55 +/- 0.41 voltage. The speed was around 3,500 rpm. It consumed less than 6 W of power, resulting in less heat production and mechanical bearing complications. The impeller vane was designed to have both radial and axial curves according to the stream surface and stream lines to reduce thrombosis and hemolysis. Eight calves weighing 80 to 100 kg (mean 87 +/- 12 kg) were used for experiments. With the calves under general anesthesia, left posterolateral thoracotomy was performed to connect the inflow tube with the atrial appendage and to anastomose the outflow tube with the descending aorta. The calves usually awoke and stood up within hours after discontinuation of anesthetics. The mean survival of the calves was 75 +/- 42 days (range 33-148 days). The terminations of experiments were mainly due to infection. During the course of pumping, no significant deterioration of liver or renal function was noted. The evaluation of serum samples from the implanted calves indicated that hemolysis was not associated with use of the T-VAD. The average daily free hemoglobin level was 8.08 +/- 3.05 mg/dl, which was less than the set limit of 20 mg/dl. The red blood cell and platelet count and hemoglobin of implanted animals were within the normal range. In our results, the T-VAD provided competent pulsatile function without severe blood damage or organ dysfunction.

Physiologic analysis of cardiac cycle in an implantable impeller centrifugal left ventricular assist device

The purpose of this study was to determine the physiologic relationship between the cardiac cycle and the nonpulsatile impeller centrifugal Taita No.1 left ventricular assist device (T-LVAD) in a chronic animal study. The relationship of the cardiac cycle, pump flow, aortic pressure, left ventricle pressure, and pump power were analyzed by 5 phases in 4 stages. The isovolumetric ventricular phase is from mitral valve closure (MVC) to aortic valve opening (AVO) and is called Stage 1. The ejection phase is from AVO to aortic valve closure (AVC) and is called Stage 2. The isovolumetric relaxation phase is from AVC to MVC and is called Stage 3. The passive filling and atrial contraction phase is from MVC to mitral valve opening (MVO) and called Stage 4. Based on evidence from the physiologic volume change of the left ventricle, the change of pump flow of the T-LVAD in a cardiac cycle by variable voltages of pump control was evaluated using animal models. After left posteriolateral thoracotomy via the fifth intercostal space under general anesthesia, the nonpulsatile centrifugal T-LVAD was implanted into 2 healthy calves. The inflow of the T-LVAD was inserted into the left ventricle through the mitral valve via the left atrial appendage. The arterial blood pressure waveform was measured and recorded on the outflow of the T-LVAD. The 4 phases of a cardiac cycle were defined as MVC-AVO (Stage 1), AVO-AVC (Stage 2), AVC-MVO (Stage 3) and MVC-MVO (Stage 4) according to the outflow pressure of the outflow of the T-LVAD and differential pressure between the outflow and inflow of the T-LVAD. We carried out the real-time waveform measurement for electrocardiogram, the outflow pressure, the T-LVAD flow and the speed, as well as open loop and constant voltage (V). In a cardiac cycle, the sensing current of the T-LVAD was inverse to the speed. The flow of the T-LVAD at the 4 stages was measured individually and analyzed with different control voltages from 10 to 18 V. The highest flow ratio of MVC-AVC/AVC-MVC was noted when the T-LVAD worked on 14 V. By using analysis methodology of the flow ratio of a cardiac cycle, the optimal physiologically effective control of the T-LVAD might be achieved.

Application of extracorporeal membrane oxygenation in adult burn patients

Adult respiratory distress syndrome (ARDS) has been the major cause of mortality in burn injury. The authors reported the experience of using extracorporeal membrane oxygenation (ECMO) to treat adult burn patient with ARDS. Three patients with burn or electric injury, around 48.9% of body surface area over second-degree burns, developed ARDS after resuscitation. All had positive blood culture and depended on a ventilator more than 5 days before ECMO. Venovenous (VV) ECMO was started at the beginning of severe respiratory failure with an oxygen index of 61.6 +/- 15.5 cm H2O/mm Hg (> or =40 cm H2O/mm Hg), partial arterial oxygen tension to inspired oxygen fraction (Pa(O2)/Fi(O2)) of 46.1 +/- 7.0 mm Hg (< or =200 mm Hg), positive end expiratory pressure (PEEP) of 15.7 +/- 1.6 cm H2O (> or =10 cm H2O), alveolar-arterial difference in oxygen concentration (A-a D(O2)) of 618.9 +/- 19.3 mm Hg (> or =300 mm Hg), and lung compliance of 17.3 +/- 4.6 ml/cm H2O (< or =30 ml/cm H2O). The VV type had to be converted to the newly designed veno-venoarterial (V-VA) ECMO due to the myocardial dysfunction. Two of three patients survived. The duration of ECMO was 160.2 +/- 51.1 h. Two patients received debridement of escar during ECMO support and desmopressin infusion, and no increased bleeding or coagulopathy was found. The respiratory parameters were significantly improved after ECMO, especially in the survivors. ECMO is also suitable for ARDS in adult burn injury.

Growth of endothelial cells on different concentrations of Gly-Arg-Gly-Asp photochemically grafted in polyethylene glycol modified polyurethane

To improve endothelial cell adhesion and growth on the surface of polyethylene glycol modified polyurethane (PU-PEG), cell adhesive peptide Gly-Arg-Gly-Asp (GRGD) was photochemically grafted to the surface. The surface grafted GRGD-N-Succinimidyl-6-[4'-azido-2'-nitrophenylamino]hexanoate (SANPAH) on a PU-PEG surface was performed by adsorption and subsequent ultraviolet irradiation. Fourier transform infrared spectra (FTIR) and electron spectroscopy for chemical analysis (ESCA) confirmed the GRGD grafted to form a PU-PEG-GRGD surface. The composition fraction of nitrogen calculated from ESCA analysis for the PU-PEG-GRGD surface was well correlated with the concentration of GRGD to be immobilized. Human umbilical vein endothelial cells (ECs) were well adhered and growing on the PU-PEG-GRGD surface. Moreover, the viability of ECs growing on PU-PEG-GRGD surfaces, analyzed by MTT test, was also well correlated with the GRGD concentrations immobilized on the surface. With photochemical techniques, we could manipulate different contents of GRGD to form multiple regions of PU-PEG-GRGD surface that could enhance the growth of ECs on the surface, and the enhancement efficiency was well correlated with GRGD contents.

Preliminary result of an algorithm to select proper ventricular assist devices for high-risk patients with extracorporeal membrane oxygenation support

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is not suitable for long-term support because of its high incidence of complications. Conversion from ECMO to ventricular assist device (VAD) is reasonable, and we have developed a simple algorithm for selecting proper VADs for these ECMO-supported patients.

METHODS

We converted 12 patients who were receiving ECMO support to VAD for bridge to transplantation. Group I (n = 6) was converted directly from ECMO to VAD. Group II (n = 6) underwent stage conversion. We added left atrial drainage to ECMO because of lung edema or marked left heart distension. We discontinued drainage after recovery of right heart function. Group II had more unfavorable risk factors for VAD before ECMO.

RESULTS

Three patients (50%) in Group I received biventricular VADs. The other 3 patients were converted to left ventricular assist device (LVAD), but only 1 (16.7%) experienced successful conversion. We successfully converted 5 patients (83.3%) in Group II to LVAD without right VAD, and 4 of them could be weaned from the ventilator. The multiple-organ dysfunction score gradually improved in Group II despite additional surgery. Two patients in each group received heart transplantation and survived long term.

CONCLUSION

Using a conversion protocol provides a good guideline for making decisions. According to the protocol, right heart and pulmonary function can be clearly assured before shifting to LVAD in these critical ECMO-supported patients.

Successful resuscitation of acute massive pulmonary embolism with extracorporeal membrane oxygenation and open embolectomy

Acute massive pulmonary embolism is usually fatal if not treated aggressively, but the management is not standardized. Open pulmonary embolectomy retains a role in the treatment of this disastrous disease. Extracorporeal membrane oxygenation has been used for cardiopulmonary support in some patients with life-threatening pulmonary embolism. This article details our experience of a 58-year-old woman suffering from acute cardiopulmonary collapse caused by massive pulmonary embolism. Under extracorporeal membrane oxygenation support, the patient received pulmonary angiography and underwent open embolectomy for a definitive treatment.

Heart transplantation and the Batista operation for children with refractory heart failure

Medically refractory heart failure may be present in children with cardiomyopathy (CMP) or complex congenital heart disease (CHD). In adults, the surgical management of this condition is either heart transplantation or the Batista operation. From March 1995 to January 2000, a total of 6 children, aged from 1 to 16 years, with medically refractory heart failure associated with CMP or complex CHD underwent cardiac transplantation and one of them also had the Batista operation as a bridge to transplantation. One of the 6 patients died of intractable sepsis 17 days after the operation, but the other 5 were discharged with satisfactory hemodynamics. Immunosuppressive agents, including azathioprine, cyclosporin or FK-506, were given. One patient experienced moderate acute rejection, but it was controlled by FK-506, OKT-3 and solumedrol. However, another suffered from lymphoproliferative disease 8 months after transplant, but it was controlled by intravenous immunoglubulin, alpha-interferon and acyclovir. Cardiac function during serial follow-up (range, 1 month to 5 years) revealed normal systolic and diastolic function and none received any anticongestive medications. Almost all patients received an oversized donor heart. The left ventricle (LV) mass was remodeled, initially as an decrease and later as an increase. The patient who underwent the Batista operation was discharged 1 month after the operation with an increased LV ejection fraction (from 10% to 22%). She was successfully bridged to heart transplantation 7 months after the Batista operation. The results of cardiac transplantation in growing children are satisfactory and remain the mainstay of surgical treatment for medically refractory heart failure in these patients. However, with a shortage of donor hearts, the Batista operation may be adopted as a bridge to heart transplant with a fair response.

Impact of cadaveric organ donation on Taiwanese donor families during the first 6 months after donation

OBJECTIVE

Organ donation is a complex decision for family members of Asian donors. The impact of cadaveric organ donation on both Chinese and Western donor families has not been well investigated within a cultural framework. The purposes of this study were to follow Chinese family members' appraisal of their decision to donate organs, to explore the possible negative and positive impacts of organ donation on their family life, and to determine what help they expected from healthcare providers during the first 6 months after donation.

METHODS

Twenty-two family members (10 men and 12 women) of cadaveric organ donors who signed consent forms at an organ transplant medical center in Taiwan participated in this project and completed in-depth interviews during the sixth month after donation.

RESULTS

Participants were 25 to 56 years old (mean = 48.15 +/- 8.31 years). The type of kinship of the participants included the donor's parents, older sister, and spouse. Subjects reported several negative impacts: worry about the donor's afterlife (86%), stress due to controversy among family members over the decision to donate (77%), and stress due to others' devaluation of the donation (45%). Positive impacts reported by the subjects included having a sense of reward for helping others (36%), having an increased appreciation of life (32%), having closer family relationships (23%), and planning to shift life goals to the study of medicine (9%). Subjects expected the transplant team to provide information about organ recipients (73%), to submit the necessary documents so that family members could receive healthcare payments from the insurance company (68%), to help resolve legal proceedings and settlements associated with accidents (64%), and to not overly publicize their decision to donate (64%).

CONCLUSIONS

Although all of the subjects reported that organ donation was the right decision, the decision to donate did not protect Taiwanese donor families from negative psychocognitive bereavement. The impacts of organ donation were affected by the subject's social cultural, spiritual, and legal context and the nature of their bereavement.

Perfusionist-transmitted bacterial mediastinitis in a heart transplant recipient

We report the case of a 56-year-old man who developed bacterial mediastinitis with methicillin-resistant Staphylococcus aureus after undergoing heart transplantation. He had a history of insulin-dependent diabetes mellitus and prior cardiac surgery. To find the source of nosocomial infection, we cultured nasal swab specimens from all hospital personnel involved in this operation. We used antibiotic sensitivity profiling and pulsed-field gel electrophoresis to subtype the involved microorganism. The S. aureus isolates from the patient and the perfusionist were identical to each other and were different from the strains previously found in our hospital. It is almost certain that the S. aureus mediastinitis in this patient was transmitted from the perfusionist. We recommend obtaining cultures from hospital staff members when there is an outbreak of staphylococcal infection.

Role of electrophysiological studies and arrhythmia intervention in repairing Ebstein's anomaly

BACKGROUND

Repairing Ebstein's anomaly without correction of associated arrhythmia may result in sudden death. Catheter or surgical ablation is indicated for various symptomatic tachyarrhythmias in Ebstein's anomaly.

METHODS

Between October 1973 and October 1997, 30 patients with Ebstein's anomaly underwent surgical repair in our hospital. Tricuspid valve replacement was performed in 13 patients, tricuspid annuloplasty and valvuloplasty in the remaining 17 patients. Preoperative electrophysiological studies were performed in 11 patients after 1980. Concomitant arrhythmia ablation was done in 10 patients: 4 for Wolff-Parkinson-White syndrome, 2 for atrioventricular (AV) nodal reentrant tachycardia, one for ventricular tachycardia and 3 for paroxysmal atrial flutter and fibrillation.

RESULTS

No mortality or major morbidity occurred in those patients undergoing arrhythmia intervention. There were 7 deaths in total; 6 died suddenly, and the other died of purulent mediastinitis. None of the 6 sudden deaths underwent preoperative electrophysiological evaluation. The functional recovery was good in all survivals.

CONCLUSIONS

We conclude that detailed preoperative electrophysiological evaluation in patients with Ebstein's anomaly is mandatory. Aggressive surgical intervention of the associated arrhythmias in addition to anatomic correction can reduce the sudden death in Ebstein's anomaly.

Ventricular remodeling of the native heart after heterotopic heart transplantation

Although ventricular remodeling after long-term unloading of the heart has been reported in patients after the use of medical therapy or left ventricular assist devices, it has rarely been reported in patients after heterotopic heart transplantation. Here, we describe a case of ventricular remodeling of the native heart after heterotopic heart transplantation. A 61-year-old man with end-stage dilated cardiomyopathy underwent heterotopic heart transplantation because of high pulmonary vascular resistance and a small donor heart. After the operation, echocardiography showed ventricular remodeling of the native heart, with decreased size and improved contractility of the left ventricle. Six months after the transplantation, acute graft failure of the donor heart occurred. However, the patient remained in good condition with the support of the improved native heart.